Assuring the best care at the lowest cost

We improve the quality of care and lower healthcare costs by making sure your group members receive the most appropriate care.

It’s no secret that healthcare costs are too high.

Too large a chunk of healthcare costs is spent on waste – services, procedures, and medications that your group members don’t really need. And, some services just cost too much. Our URAC-accredited Medical Management services, performed by our in-house clinical team, ensure that your members get the right care at the right time, and at the right price.

Utilization Management

Our utilization management programs promote the delivery of high quality, medically necessary, and cost-efficient healthcare through individual case review and assessment using our custom-built medical management platform. The program focuses on all aspects and stages of the patient’s care by utilizing prior authorization, concurrent and retrospective review, and discharge planning for medical and behavioral health conditions.

Case Management

Some members need a little more focus and attention from clinicians. Our complex case management program addresses the unique needs of these members while improving member health and lowering costs. We identify members with complex and catastrophic conditions who would benefit from an individualized, tailored case management program. Through direct member outreach, registered nurses establish one-on-one relationships with members, uncover their needs and challenges, and help them attain their personal wellness goals.

Across our book of business, our case management program has shown the following impressive results:

%

decrease in emergency room utilization

%

decrease in admissions

%

reduction in cost per member

Other Medical Management services available

Claims Repricing & Payment Integrity

We drive customer savings through in-depth clinical claim reviews by our in-house Medical Management team. Our post-service pre-payment review ensures all codes are correct, and we detect fraud and abuse.

Pharmacy Benefits Management (PBM)

With drug prices a major factor in rising healthcare costs, we use best-of-breed clinical capabilities to lower your total cost of care. When integrated with a health plan, our PBM services gain more insight into the patient’s care and can further reduce costs, improve the quality of care, and streamline administration.

Care Coordination programs

Care Coordinators schedule appointments for your group members for high-priced services, including genetic testing and MRIs, to ensure your members visit preferred providers in terms of quality and cost.

Pain Management and Opioid Oversight program

Through a multifaceted approach, we reduce dependence on opioids for new and persistent users, improving the quality of life of your members and reducing your drug costs. Learn more about our proven, effective Pain Management and Opioid Oversight program.